7 stations / 107 steps/ 15 script lines
Physical examination
Signpost, sanitize, and narrate: examiners score what they hear you doing. Each station carries its maneuvers, normal ranges and special tests; the tables below can be read or covered for self-testing.
0 of 107 steps
Watch it done
0/2General impression
- Signpost and sanitize“Now I am going to start a general physical examination and will be describing what I do. I will start by sanitizing my hands, and begin by sharing my general impression of your appearance.”
- Comment: stated age, position, pain or acute distress, dishevelled or put together, level of alertness, body habitus (thin, cachectic, obese), pallor or diaphoresis.
0/2Pulse
- Palpate the radial pulse at the base of the thumb for 30 seconds and double; compare both sides for symmetry.
- Report rate, grade, and rhythm.Normal 60 to 100 bpm. Tachycardia over 100, bradycardia under 60.Grade: 0 absent, 1+ diminished, 2+ brisk and expected, 3+ bounding.Rhythm: regularly regular, regularly irregular, irregularly irregular.
0/1Respiratory rate
- Inspect breathing for 30 seconds while still holding the wrist.Normal 12 to 20 per minute at rest. Bradypnea slow, tachypnea fast, hyperpnea deep (Kussmaul breathing).
0/3Blood pressure
- Screen first“Have you smoked, had caffeine, or engaged in physical activity in the last 30 minutes? Which arm do you prefer? Can I have you seated a little closer, with your back supported and your legs and ankles uncrossed?”
- Locate the brachial artery 2 cm above the cubital fossa; palpation technique first: inflate to occlude, deflate at 2 mmHg per second to find systolic.
- Auscultation technique: inflate 20 mmHg above the palpated estimate to clear the auscultatory gap; stethoscope over the brachial artery; Korotkoff phase 1 is systolic, phase 5 (disappearance) is diastolic.Normal adult systolic 90 to 140, diastolic 60 to 90 mmHg.Children: 50th centile systolic is 90 plus twice the age; diastolic is two-thirds of systolic.Orthostatic drop: systolic fall of 20 or diastolic fall of 10 on standing.Pulsus paradoxus: an inspiratory fall in systolic pressure of more than 10 mmHg, as in cardiac tamponade or severe asthma.Auscultatory gap: a silent phase that can underestimate systolic or overestimate diastolic.
0/1Temperature
- Fever thresholds: rectal or tympanic over 38.0, oral over 37.8, axillary over 37.2 degrees C.Hyperthermia: thermoregulation fails. Hypothermia: core temperature below the normal range.
9 steps left in this station.
The acute abdomen
Thirteen diagnoses by history, risk, examination and investigations.
| Row | History | Risk factors | Examination | Investigations |
|---|---|---|---|---|
| Peptic ulcer disease | Epigastric pain, discomfort or bloating, constant or episodic, tied to eating; may radiate across the upper abdomen, chest or back; nausea, weight loss, hematemesis or coffee grounds, melena | H. pylori or PUD history, ASA, NSAIDs, corticosteroids, prolonged ICU stay | Tender epigastrium; peritonitis or pallor possible | Bloodwork for anemia; endoscopy visualizes the ulcer |
| Acute pancreatitis | Acute severe epigastric pain lasting hours to days, relieved leaning forward, worse lying down, may radiate to the back; nausea and vomiting | Alcohol, gallstones, hypertriglyceridemia, hypercalcemia, family history, thiazides, azathioprine, sulfa drugs, valproate | Tender epigastrium, distension, scleral icterus; Grey Turner or Cullen sign if hemorrhagic | Raised lipase or amylase, WBC and liver enzymes possibly raised; ultrasound for gallstones |
| Biliary colic | Postprandial RUQ or epigastric pain, especially after fatty meals, minutes to hours (up to 8), pain free between; may radiate to the back or right shoulder | The five Fs: female, forty, fat, fertile, fasting | Looks well, afebrile; exam normal between episodes, RUQ tenderness during | Normal CBC, LFTs and lipase; ultrasound shows stones |
| Acute cholecystitis | The same pain but prolonged beyond 8 hours; nausea, vomiting, anorexia, fever | The five Fs | May look ill, febrile, tachycardic; tender RUQ with Murphy sign; peritonitis possible | Raised WBC, LFTs possibly raised, normal lipase; ultrasound shows stones, wall thickening, pericholecystic fluid |
| Appendicitis | Periumbilical pain migrating to the RLQ, intensifying over 24 hours; nausea, anorexia, low-grade fever | Male, under 30, family history | McBurney tenderness, peritonitis, the special signs, low-grade fever, tachycardia | Raised WBC; contrast CT or ultrasound shows an enlarged appendix |
| Bowel obstruction | Diffuse pain with distension, vomiting, constipation or obstipation, anorexia, feculent vomiting | Small bowel: surgery, hernia, IBD. Large bowel: colorectal cancer, diverticulitis. Pseudo-obstruction: narcotics, immobility, orthopedic surgery | Diffuse tenderness, distension, peritonitis, fever, tachycardia, tachypnea | Plain film: dilated loops, air-fluid levels, free air if perforated; CT for the cause |
| Diverticulitis | LLQ pain, constipation or diarrhea, nausea, anorexia, fever; bleeding is unusual (diverticular bleeding is painless and comes without inflammation) | Over 60, known diverticulosis, obesity | LLQ tenderness with or without a mass, distension, peritonitis, fever, tachycardia or hypotension when unwell | Raised WBC; CT shows wall thickening at the diverticula, free air if perforated |
| Renal colic | Intermittent flank pain radiating to the lower abdomen or groin, nausea and vomiting, hematuria, urinary symptoms, fever | Calculi history, dehydration, obesity | Writhing in pain; lower abdominal or CVA tenderness; may be febrile | Urinalysis for hematuria; KUB may show the stone (uric acid stones are radiolucent); non-contrast CT shows the stone and hydronephrosis |
| Pyelonephritis | Dull constant flank pain, fever and chills, nausea and vomiting, hematuria, variable dysuria | Female, UTI history, intercourse, spermicide, outflow obstruction | Febrile with rigors, tachycardic or hypotensive, CVA and suprapubic tenderness | Urinalysis and culture with pyuria and hematuria, raised WBC, possibly positive blood cultures |
| Ovarian torsion | Acute unilateral pelvic pain radiating to flank or groin, nausea and vomiting | Previous torsion, cysts or mass, tubal ligation, ovulation induction | Lower abdominal or pelvic tenderness, adnexal mass, fever possible | Negative beta-hCG; ultrasound shows an enlarged ovary with reduced flow and edema |
| Pelvic inflammatory disease | Lower pelvic pain, abnormal discharge, dyspareunia, fever and chills, nausea | Previous PID, multiple partners, under 25, unprotected sex, recent IUD | Uterine, cervical motion and adnexal tenderness; abnormal discharge; fever | WBC on vaginal microscopy; documented gonorrhea or chlamydia |
| Ectopic pregnancy | Cramping pain, localized or diffuse, mild to severe; vaginal bleeding after a missed period | Previous ectopic, infertility, tubal ligation or pelvic surgery, PID, IUD | Pelvic tenderness, peritonitis, bleeding, cervical motion tenderness, hemodynamic instability | Positive beta-hCG, anemia possible; transvaginal ultrasound locates the sac |
| Abdominal aortic aneurysm | Asymptomatic until rupture; then vague abdominal or low back pain, pulsatile mass, hypotension, syncope | Family history, male, increasing age, cardiovascular risk factors | Abdominal tenderness, peritonitis, pulsatile mass, instability | CT shows dilation over 1.5 times normal or over 3 cm |
The jaundiced patient
Ten causes sorted by the history, the examination and the pattern of the liver tests.
| Row | History | Examination | Bloods and imaging |
|---|---|---|---|
| Gilbert syndrome | Mild intermittent yellowing with fasting, illness or stress in a well young adult; no dark urine or pale stool | Faint scleral icterus, otherwise normal | Unconjugated bilirubin mildly raised, normal liver enzymes, normal hemoglobin and reticulocytes; nothing to image |
| Hemolysis | Fatigue, breathlessness, dark urine from hemoglobinuria; a trigger such as a new drug or infection, or a known sickle cell or G6PD history; family history of anemia or splenectomy | Pallor with icterus, splenomegaly | Unconjugated bilirubin raised, anemia with raised reticulocytes and LDH, low haptoglobin, spherocytes or sickle cells on the film; normal ALP |
| Acute viral hepatitis | A prodrome of malaise, anorexia, nausea and right upper quadrant ache, then dark urine and jaundice; travel, shellfish, contacts, injection drug use, unprotected sex, tattoos | Tender enlarged liver, low-grade fever, sometimes a rash | ALT and AST in the hundreds to thousands, conjugated bilirubin up, ALP only mildly raised; hepatitis A IgM, B surface antigen and core IgM, C antibody and RNA |
| Alcoholic hepatitis | Weeks of heavy drinking then jaundice, fever, anorexia and tender swelling under the right ribs; often after a binge or a recent stop | Fever, tender hepatomegaly, spider nevi, parotid enlargement, Dupuytren contracture; ascites and encephalopathy when severe | AST about twice ALT with both under 300, raised GGT, MCV and bilirubin, INR prolonged; ultrasound for a fatty enlarged liver and to exclude obstruction |
| Drug-induced liver injury | A new medication or supplement in the last three months: acetaminophen, amoxicillin-clavulanate, nitrofurantoin, antituberculous drugs, statins, anabolic steroids, herbal products | Often unremarkable; rash or eosinophilia with a hypersensitivity pattern | Hepatocellular, cholestatic or mixed pattern by the ratio of ALT to ALP; improves when the drug stops; viral and autoimmune causes excluded |
| Choledocholithiasis | Right upper quadrant pain after meals with jaundice that comes and goes, dark urine and pale stool; known gallstones | Right upper quadrant tenderness, no palpable gallbladder | Conjugated bilirubin and ALP raised more than the transaminases, lipase if the pancreas is involved; ultrasound shows a dilated duct and stones, MRCP or ERCP to confirm and clear |
| Ascending cholangitis | Fever with rigors, right upper quadrant pain and jaundice (Charcot triad); confusion and hypotension complete the Reynolds pentad; previous stones, a stent or ERCP | Febrile, tachycardic, tender right upper quadrant, may be septic | Raised white cells and CRP, a cholestatic pattern, positive blood cultures; ultrasound shows a dilated duct; antibiotics then urgent drainage by ERCP |
| Pancreatic head cancer | Painless progressive jaundice with pale stool, dark urine and itch; weight loss, new diabetes, back pain later; older, a smoker | Cachexia, a palpable non-tender gallbladder (Courvoisier), a hard liver edge, a left supraclavicular node | Cholestatic pattern, CA 19-9 raised; ultrasound shows dilated ducts, CT with a pancreas protocol for the mass and staging |
| Primary biliary cholangitis | A middle-aged woman with months of fatigue and itch before any jaundice; dry eyes and mouth; other autoimmune disease | Excoriations, xanthelasma, hepatomegaly, later the signs of cirrhosis | ALP and GGT raised with a normal ultrasound, antimitochondrial antibody positive, raised IgM and cholesterol |
| Decompensated cirrhosis | Years of alcohol, viral hepatitis or fatty liver; abdominal swelling, confusion or bleeding; an infection, a bleed or a new drug as the trigger | Spider nevi, palmar erythema, gynecomastia, caput medusae, ascites, asterixis, a small hard liver | Low albumin and platelets, prolonged INR, raised bilirubin, low sodium; ultrasound shows a nodular liver, splenomegaly and ascites |
The painful or swollen limb
| Row | Pathophysiology | History | Risk factors | Examination |
|---|---|---|---|---|
| Acute limb ischemia | Acute arterial blockage: embolism from arrhythmia, thrombosis, dissection, trauma | Under 2 weeks, one limb; the 6 Ps: pain, pallor, polar, pulselessness, paresthesia, paralysis; rest or night pain if critical | Atrial fibrillation, endocarditis, aneurysm, hypercoagulable states, cardiovascular risk factors | Pain and absent pulses on palpation and Doppler; occlusion on duplex or CT or MR angiography |
| Peripheral arterial disease | Atherosclerotic narrowing of lower limb arteries | Claudication: reproducible calf pain with exertion relieved by 2 to 5 minutes of rest, same distance every time, often both limbs; rest pain if critical | Smoking, diabetes, hypertension, hyperlipidemia, family history | Hair loss, thick nails, atrophic muscle, arterial ulcers, positive Buerger, ABI under 0.9, absent Doppler pulses |
| Deep vein thrombosis | Thrombus in a deep vein, usually the calf, propagating proximally; Virchow triad | Unilateral edema, erythema, warmth, tenderness; respiratory symptoms with PE | Previous DVT, obesity, age, female sex, pregnancy, leg injury, surgery, immobilization | Swollen warm red leg, unequal diameters; duplex ultrasound is the test; positive D-dimer |
| Chronic venous insufficiency | Valve incompetence or thrombotic obstruction; calf pump failure | Diffuse aching, fullness, tightness | Obesity, age, female sex, pregnancy, leg injury, prolonged standing | Edema, brown hyperpigmentation, dilated superficial and varicose veins, stasis dermatitis, venous ulcers |
| Compartment syndrome | Raised compartment pressure impairing perfusion | Pain out of proportion; impaired sensation of the toes | Reperfusion of an ischemic leg, trauma, casting, ischemia-reperfusion | Pain on palpation and passive stretch of the great toe; pulses lost late; clinical diagnosis, pressure over 30 mmHg |
Enlarged spleen versus enlarged kidney
| Row | Spleen | Kidney |
|---|---|---|
| LUQ percussion | Dull | Tympanic |
| Probing | Fingers reach medial and lateral borders but not between mass and costal margin | Fingers fit between mass and costal margin but not deep to its medial and lower borders |
| Notch | Palpable on the medial border | None |
| Growth | Extends past the midline toward the RLQ, moves with respiration | Enlarges down and forward, does not cross the midline |
Hypovolemia versus hypervolemia
| Row | Hypovolemia | Hypervolemia |
|---|---|---|
| Vitals | Tachycardia, tachypnea; postural drop of 20 systolic or 10 diastolic, pulse rise of 30 | May be normal; S3 or murmur, laboured breathing, tripod position |
| JVP | Under 2 cm or not visible supine | Over 4 cm; abnormal hepatojugular reflux |
| Chest | Rapid breathing | Inspiratory crackles; dull bases from effusion |
| Skin and mucosa | Dry mucous membranes and axillae, tongue furrows, sunken eyes, confusion | Pitting peripheral edema, anasarca |
Recall quiz
Name the sign
A maneuver is described; name it.
Score 0 / 12Streak 0
Shuffling the deck...
Demonstration videos are embedded from their creators’ own YouTube channels (Geeky Medics and Stanford Medicine 25) and remain theirs; each frame credits the channel and links out to it.